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25. In a Gentle Way

14 July 2008

It would be fair to say that before coming to Chad, in the months leading up to this mission, I was expecting something alien. Conditions and life-ways so extreme and dimensionally different from mine that I would struggle to connect with them. In anthropological parlance, I exoticised the other. This is almost never a good thing. It is also somewhat inevitable, at least when exploring new terrain, however much you try and keep it in check. In order to minimize the anxiety of the unknown and unexpected, we start entertaining possibilities. Like mythologies and daydreams, they have no direct correspondence with reality, but these animated exhalations are good to think with. Like a mental jungle-gym. The problem is not in doing this. Quite to the contrary, exploring hidden assumptions and their entailments are the scaffolding of psychotherapy. Or most any insight-oriented activity, really. Rather, the problem would be in affording these guesses, assumptions or projections a stability that does not reflect their arbitrariness and self-soothing origins. In the first post that I wrote, I asked some semi-rhetorical questions:

"How can a psychiatrist WWHUUMMP parachute into central Africa and expect to do anything useful?"

"*Tense sigh* These people have suffered such incomprehensibly intense, sustained, and unpredictable trauma, and the situation remains horrendous!! What do you say to a person who has lost his or her family, community, and livelihood?! What do you say to the woman who has been repeatedly raped when going out at night for firewood, and will continue to do so because her children will die without cooked food?! What do you say to say to a child who has been orphaned, neglected, and abused?! What can a psychiatrist do?!?"

Both questions are of the same form: what can a psychiatrist do when he or she has no clue how to connect with unfamiliar circumstances? The uncertainty was palpable—and sensationalistic.

And, like all rhetorical questions, they are also simple statements: “Holy shit, this is gonna be weird/hard.” “So much specialized training, but it could be useless.” And so on. But like myths and dreams, rhetorical questions are also projections, and answering them is like playing on the jungle gym; it’s good to try and answer them, beg them, or hazard a guess.

And here’s what I have come up with: living in Farchana is not so dimensionally different that you can’t hit the ground running; I focused on the victimization and unrest and did not project how suffering would become knowledge, strength, and a tighter sense of community than I have ever seen. In what I could only call an honest act of remarkable conceit, I thought that psychiatric training could help me through this. Only insofar as any formal education informs and buttresses ones actionable humanity will it be useful. Pragmatism has primacy. The lessons learned have to some extent cleaned off the post-modern/neurotic shelf... sure, the thoughts still spin, but they end with the usual question: now what would be useful?

OK, I have to qualify this. (So much for being less neurotic.) Many things ARE exotic in a way, but so are things back home. Even professionally, the mysterious is ever-present. Despite training and clinical experience, eating disorders, for example, remain unfathomable. They exist in practice, but not in resonant theory. For that matter, alcoholism, psychosis, and lots more retain this air of dimensional disconnectedness. Of course you don’t have to be a recovered addict to treat addiction any more than you have to be a gymnast to train one of them. Generations of fat and balding Eastern Europeans and post-Soviet types have provided much empirical evidence to this fact. You get my point. I thought that the foreign and different would be more bizarre than the local and different.

Inspector Gregory (Scotland Yard detective): "Is there any other point to which you would wish to draw my attention?"
Sherlock Holmes: "To the curious incident of the dog in the night-time."
Inspector Gregory: "The dog did nothing in the night-time."
Sherlock Holmes: "That was the curious incident."

The dog that didn’t bark in the night. Some things should have seemed odd for years, but needed to be made contrast with the Farchana sky to become visible. Ethics, for one. In a way, ethics in Canadian medicine is dead. In the past ten years, I have watched nearly every discussion about ethics in medical care quickly and contritely devolve into a discussion on medico-legal ethics: what can and should a doctor do to protect him or herself from being sued (most often wrongfully)? This does not mean that most doctors are not deeply ethical and conscientious. But the near complete absence of group discussions on purely ethical matters is a problem. (Most likely the heart of the problem is that when a lecture on medical ethics is organized, they send in a lawyer rather than an ethicist to lead discussions.)

The only question that I need to ask out here in Farchana is “what will help in a meaningful way?” If I need to hire staff, contract for the construction of work-space, order supplies, or bring in resources, I just need to justify their utility in the service of minimizing suffering, respecting human dignity, and providing options. Maybe a part of this is the luck of being placed in my particular project, but I feel like I am working with an extended team that lives its principles. That plaque on the institutional wall that says “mission statement” is usually not worth the piece of paper that it’s written on; it’s an endless stream of platitudes. Not here. From what I have seen, the principles of MSF-Holland reach the bottom floor. It’s a pleasure to work in such an environment.

What informs this humanitarian space more than anything else is a pervading sense of inclusiveness and equality. And it needs to be as firm as ever. This is not an easy environment to live and work in. Despite having a cushy life in comparison to our neighbours, it is taxing. Amenities are minimal. And lets face it, the human stain hangs low. I feel that stain, and it is not from the outside. It comes from within. The stain has seeped through. The same morning that I looked at pictures of porsches (that were sent to me from a friend who had just bought one), a child of three years came to the health center with injuries consistent with sexually abuse. And I saw two kids with neurodegenerative disorders whose parents had to hear the bad news. Then a woman who was beaten by her husband for refusing his advances. It doesn’t get easier. This is to point out contrasts we all know exist. It is not to fuel guilt. Really.

This brings me to something else that is notable in its near complete absence: loneliness. I would guess that isolation and loneliness are some of the most common complaints in a psychiatric practice in Canada. And outside of practice, too, which is more my point. But here the sense of community is tightly woven so that people do not fall through. I will never forget the response to Fatna, the young girl who cried in the night with nightmares of men on horseback: the women of the village all went to her and they sat together. Or the religious community that took Youssef into their fold as he sat with them for hours praying. Contrast this with the fact that despite many of our expat team coming from the same area of Montreal, we had never met. This is, of course, not odd, the Plateau area being densely packed. What is striking is the fact that the Chadian staff find this hard to believe. “You don’t know your neighbour? How is that possible.”

Anyone who thinks that they will give more than they will take from doing work with MSF (and any NGO field-work, likely) is off their rocker. My opinion. In the words of Ivan, the project coordinator in Farchana, “A life of adventure truly does still exist, and it’s good to know that.” Life is many things here, but one of them is not dull. Or senseless. Quite to the contrary, I have not found a learning curve more steep and work more stimulating. But for the most selfish of reasons, I would have come here many times over. In a way, even the utter chaos of this space resonates with inner or personal chaos. The extent to which some people live with this tension and have it so little reflected by their external environment is one measure of their private madness. I have met many who breathe deeply when they speak of life in various African countries, and finally return for the next mission. It is a type of weightlessness. I do not know how I will transit from this space back home. I am starting to breathe deeply here. I will miss some of those staff, patients and their families that I have gotten to know. I will deeply miss the mental health team.

This is likely the last post that I will write; my contract is about done and I am going home. Thank-you, in a gentle way, for reading and taking part in the dialogue, the ranting, the giddiness, the navel-gazing, the aching for clarity, the rage, the amusing bits. This has become more personal than I expected; it's been an important part of the mission, this chatter between a traveller and his shadow.

The light of this computer screen attracts bugs. The rains have come and the air is swarming with insects of all shapes and sizes. Too much!